Rapid ART Program Initiative for New Diagnoses (RAPID), a citywide initiative, began in 2013 as part of San Francisco’s Getting to Zero campaign. RAPID was designed to connect people with a new HIV diagnosis to antiretroviral therapy (ART) within five days of diagnosis and within one day of their initial care visit. Through RAPID, linkage navigators located at the San Francisco Department of Public Health (SFDPH) Linkage, Integration, Navigation, and Comprehensive Services (LINCS) team counseled people on HIV care, identified an available clinician capable of immediately prescribing ART, scheduled the clinical appointment, and connected people to additional support services. RAPID led to a reduction in median time between initial diagnosis and both ART initiation and viral suppression.
San Francisco, CA
Rapid ART initiation is defined as beginning ART the same day or within a few days of a person’s HIV diagnosis.1 It has been linked to reduced time to viral suppression and improved retention in care. For example, a study at the Ward 86 HIV Clinic at San Francisco General Hospital, a rapid ART pioneer, demonstrated that the median time from initial diagnosis to viral suppression was 1.8 months for people who received rapid ART, compared to 4.3 months for people receiving the standard of care.1 Since rapid ART initiation was first piloted in the Ward 86 HIV Clinic in 2013, it quickly became the local standard of care. However, ART initiation is still often delayed in many other clinical settings. In 2017, 66% of people with a new HIV diagnosis were linked to care within 90 days.2
RAPID is rooted in providing immediate access to HIV medical care and ART. ART must be initiated within five days of diagnosis and within one day of a person’s initial care visit. Once a person receives a positive HIV test from a local clinic or testing site, the results are immediately communicated to the individual and the SFDPH linkage navigator team (LINCS). The LINCS navigator then connects the person to an HIV provider or clinic who has been trained on RAPID implementation. Provider selection is based on the person’s health care coverage status and care preferences, using a directory of HIV clinical providers as a resource. An intake appointment with the care provider is then scheduled for the same day, if possible, in which the person will receive a prescription for ART. If the individual has already been linked to care by their provider, a testing site, or by a navigator outside of SFDPH, LINCS confirms that the person has been linked to care.
The linkage navigator provides health care coverage navigation and counseling services to all people who receive a positive HIV test to help them feel comfortable moving forward with immediate care. Linkage navigators also take a psychosocial history so they can match people with an HIV provider the individual feels comfortable with and connect them with additional supportive services in the community.
The evaluation included 1,354 people who received a new diagnosis of HIV in San Francisco, California from 2013 to 2017. During RAPID implementation, the median days from diagnosis to viral suppression decreased, as did the time from first care visit to ART initiation. People who received a rapid ART start (defined as diagnosis to care within 5 days and ART initiation within 1 day of first care visit) were more likely to be virally suppressed within 12 months compared to those who did not receive a rapid start.
| Category | Information |
|---|---|
| Evaluation data | The evaluation leveraged SFDPH surveillance data, including date of diagnosis, initial CD4 count or HIV RNA level, the first prescription of ART, subsequent HIV RNA test results, and sociodemographic variables. |
| Measures |
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| Results |
*statistically significant |
Source: Bacon O, Chin J, Cohen SE, et al. Decreased time from human immunodeficiency virus diagnosis to care, antiretroviral therapy initiation, virologic suppression during the citywide RAPID initiative in San Francisco. Clin Infect Dis. 2021; 73(1), e122 – e128.
Creation of a steering committee. Getting to Zero received one-year funding through SFDPH for a part-time physician and full-time staff member to detail the logistics of establishing RAPID. Part of this work involved creating a steering committee with the purpose of designing and executing the RAPID initiative. The committee included individuals from various professional backgrounds, including nurses, physicians, pharmacists, social workers, linkage navigators, and program administrators. Individuals from leading HIV care providers, such as SFDPH, the University of California San Francisco, Kaiser Permanente, and the San Francisco AIDS Foundation, were also included. Steering committee members were experienced in implementation science, protocol creation, clinical care, case management, benefits navigation, and medical education. The committee developed protocols and instructional materials, communicated with program partners, and delivered updates at public forums. During the first phase of program development, the committee convened every four to six weeks.
Building capacity through staff training. Clinical staff, linkage navigators, and social workers were trained in RAPID procedures while performing their regular activities. They were also supplied with additional reference documents designed by the steering committee. This training made RAPID implementation possible because staff knew to immediately schedule the clinical appointment for the ART prescription without waiting for a confirmatory HIV test. Training was provided continuously throughout the program.
Defining the person’s journey. Prior to program launch, the steering committee identified key steps in the person’s journey that would shape RAPID implementation. These steps needed to occur over no more than a few days, be replicable across HIV testing sites, and lead to the initiation of ART. For RAPID, these steps included: 1) communicating a positive HIV test to a linkage navigator; 2) immediate linkage to an HIV provider within the RAPID directory; 3) initiation of medical care and support services; and 4) establishment of long term HIV care. Each of these steps included defined points of consideration. For example, during step three, the linkage navigator was instructed to consider the psychosocial fit of the person and the HIV provider.
Resource directory development. The steering committee created an up-to-date directory of clinical providers and support services organizations. This list allowed the linkage navigators housed at SFDPH, participating clinical providers, and HIV testing locations to better coordinate care across service delivery locations. Linkage navigators used the directory to identify providers who were trained in RAPID implementation and were also a good psychosocial fit for individuals.
- Program sustainability will vary depending on the availability of health care and support services. San Francisco has implemented a robust safety net system that is bolstered by federal and state medical benefits initiatives, such as the AIDS Drug Assistance Program (ADAP), expanded Medicaid, and city health care coverage. This comprehensive system guarantees access to medical care, including ART, for nearly all individuals, irrespective of their health care coverage, income level, or immigration status.1 Without these multiple funding streams, RAPID may be less sustainable.
- Steering committee members mostly donated their time, with the exception of the part-time physician and full-time staff member funded by the SFDPH at the beginning of RAPID implementation. This increased the sustainability of RAPID, as the steering committee did not require extensive funding after the first year.
- The sustainability of RAPID was increased by repurposing resources that were already available in the care continuum. Educational materials were largely created by the steering committee, which donated their time. Those materials were distributed to clinicians who agreed to adopt RAPID as their regular clinical practice, and to the linkage navigators housed at SFDPH. Finally, data to assess program impact came from measures SFDPH were already collecting as part of routine HIV surveillance.
- Reducing the time from HIV diagnosis to viral suppression involved making enhancements at each stage of the care continuum, including the notification of a positive HIV test outcome, navigating health care coverage, facilitating access to care, optimizing patient flow at the clinic level, and influencing clinical prescription practices.
- Rapidly starting individuals on ART does not completely address all barriers to care maintenance, especially among those who are economically disadvantaged and face psychosocial challenges. While the vast majority of people who had a rapid ART start reached viral suppression, more work is needed to ensure viral suppression is reached and maintained. Although initiating ART immediately upon diagnosis is a viable option for people across all sociodemographic categories, disparities remained in time from diagnosis to viral suppression among people who inject drugs, African Americans, and people 30–39 years of age. This indicates there may be additional barriers to care that were unaddressed for these populations.
- Some people may be reluctant to immediately begin ART. Encouraging people to accept a rapid start is a process that needs to be practiced. In the first year of implementation, rapid ART was initiated for only 2% of people diagnosed citywide. This increased to 28% by 2017. Delays in scheduling initial care visits with HIV providers, and personal refusals to begin ART prevented a rapid start for all people with a new HIV diagnosis. However, the percentage of people who successfully received a rapid start on ART increased with each year of RAPID implementation, indicating process improvements were being made.
- Bacon O, Chin J, Cohen SE, et al. Decreased time from human immunodeficiency virus diagnosis to care, antiretroviral therapy initiation, virologic suppression during the citywide RAPID initiative in San Francisco. Clin Infect Dis. 2021;73(1), e122 – e128. doi:10.1093/cid/ciaa620
- Bacon O, Coffey S, Hsu L, Chin J, Havlir D, Buchbinder S. Development of a citywide rapid antiretroviral therapy initiative in San Francisco. Am J Prev Med, 61(5S1), S47-S54. doi.org/10.1016/j.amepre.2021.06.001
- Buchbinder S, Havlir D. (2020). Getting to Zero San Francisco: A collective impact approach. J Acquir Immune Defic Syndr. 2020; 83(Suppl 3), S176-S182. doi.org/10.1097/QAI.0000000000002200
- Bacon O, Coffey S, Hsu L, Chin J, Havlir D, Buchbinder S. Development of a citywide rapid antiretroviral therapy initiative in San Francisco. Am J Prev Med, 61(5S1), S47-S54. doi.org/10.1016/j.amepre.2021.06.001
- Bacon O, Chin J, Cohen SE, et al. Decreased time from human immunodeficiency virus diagnosis to care, antiretroviral therapy initiation, virologic suppression during the citywide RAPID initiative in San Francisco. Clin Infect Dis. 2021;73(1), e122 – e128. doi:10.1093/cid/ciaa620
